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Transdiagnostic interventions, such as the Unified Protocol, address both depression and anxiety and focus on the shared temperamental core of psychological disorders, which have been shown to impact functional outcomes as well.

Two Sides of the Same Coin: A Randomized Clinical Trial of the Unified Protocol for Addressing Depression and Anxiety in People With Multiple Sclerosis

From the Division of Multiple Sclerosis and Neuroimmunology, The Ohio State University, Columbus, Ohio, United States (YZ) and the Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (SAM). 

Yinan Zhang, MD: yinan.zhang@osumc.edu; Sarah Morrow, MD: sarah. morrow@albertahealthservices.ca.

As the population with multiple sclerosis (MS) ages, clinicians are increasingly caring for older adults living with the disease. Age profoundly impacts MS disease course by reducing focal inflammatory activity associated with relapses and new T2 hyperintense lesions on MRI, while increasing the risk of developing progressive MS.

 These changes affect the use of MS disease-modifying therapies (DMT), which are more effective in treating relapsing MS and notably less useful in slowing disability accumulation in progressive MS. Adverse reactions to DMTs are also more frequent in older adults with MS, which can lead to higher risks of infection and lymphopenia.

Older adults with MS also face unique and overlapping symptoms of both aging and MS. Geriatric conditions such as frailty, multimorbidity, and polypharmacy are often present in older adults with MS and contribute to the clinical complexity of discerning age-related changes from MS progression.

 Additional barriers impede access to care caused by impaired mobility, financial constraints, and limited availability of multidisciplinary specialists. These common geriatric issues require increased awareness from neurologists and other health care professionals, who often lack formal geriatric training.

International Journal of Multiple Sclerosis Care 

), we focus on care for older adults with MS and issues that commonly occur and significantly impact their quality of life. The core of the issue comprises 4 review papers containing discussion and recommendations based on a consensus conference organized by the Consortium of Multiple Sclerosis Centers (CMSC) that took place at the CMSC annual meeting in Nashville, Tennessee, from May 29 to June 1, 2024. These papers address:

The interaction between the aging process and MS disease course;

DMT use and discontinuation in older adults;

The effects of comorbidity and polypharmacy; and

The value of multidisciplinary care and challenges in access to care for this population.

In preparation for the consensus conference, we formed a panel of clinicians with expertise on aging and MS and conducted a needs assessment survey on aging and MS. From the responses, we developed the aforementioned focus areas and assembled multidisciplinary working groups to summarize each topic based on “what we know,” “what we don’t know,” and “best practices and future directions for research.” Each group’s findings were presented at the conference and discussed among the full panel. A summary of the meeting was first published on the CMSC website and has since been adapted for this 

special issue on aging and MS. In addition, this special issue features original research on aging and MS, such as the 

, examining discrepancies between physical and psychosocial status in older adults with MS. We will continue to welcome additional papers related to aging and MS until the close of 2025.

As the general population ages, older adults are becoming the predominant demographic group in many parts of the world, and this trend is noted in the MS field as well. This special issue conveys advances made in the care of older adults with MS. However, it is also meant to be a call to action: While great strides have been made in understanding the mechanisms and effects of aging in the general population, there is still much that is unknown in aging research, especially about how aging affects individuals with MS. Health care providers should incorporate geriatric assessments into the care of people with MS, recognize the impact of aging on the course of MS, and understand the psychosocial impact of aging with MS, all while navigating the limited but growing information that guides our decision-making. While significant progress has been made in our understanding and treatment of MS in older adults, there is still much to learn from science about the experience of aging with MS.

As the population with multiple sclerosis ages, clinicians are increasingly caring for older adults living with the disease.

Letter From the Guest Editors - Volume 27, Theme II

To access the article and evaluation online, go to 

The target audience for this activity is physicians, advanced practice clinicians, nursing professionals, rehabilitation professionals, mental health professionals, social workers, and other health care providers involved in the treatment of patients with multiple sclerosis (MS).

Identify sexual health disparities in sexual and gender minority individuals with MS and recognize how these affect clinical care.

Apply inclusive sexual history-taking techniques and incorporate affirming, individualized strategies to manage sexual dysfunction and reproductive health concerns in this population.

In support of improving patient care, this activity has been planned and implemented by the Consortium of Multiple Sclerosis Centers (CMSC) and Intellisphere, LLC. The CMSC is jointly accredited by the Accreditation Council for Continuing Medical Education, the Accreditation Council for Pharmacy Education, and the American Nurses Credentialing Center, to provide continuing education for the health care team.

This activity was planned by and for the health care team, and learners will receive .5 Interprofessional Continuing Education credit for learning and change.

The CMSC designates this journal-based activity for a maximum of .5 

™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The CMSC designates this enduring material for .5 contact hour of nursing continuing professional development (none in the area of pharmacology).

As a jointly accredited organization, the CMSC is approved to offer social work continuing education by the Association of Social Work Boards Approved Continuing Education program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive .5 general continuing education credits.

It is the policy of the CMSC to mitigate all relevant financial disclosures from planners, faculty, and other persons that can affect the content of this CE activity. For this activity, all relevant disclosures have been mitigated.

), has served as physician planner for this activity. He has disclosed no relevant financial relationships. 

, has disclosed no relevant financial relationships. Authors 

, have disclosed no relevant financial relationships.

CMSC, and Intellisphere, LLC, who are in a position to influence content have disclosed no relevant financial relationships. 

continuing education director, has served as a planner and reviewer for this activity. She has disclosed no relevant financial relationships.

Release date: August 25, 2025; Valid for credit through: September 1, 2027.

Review the continuing education information, including learning objectives and author disclosures.

Complete the evaluation, which is available at 

Statements of Credit are awarded upon successful completion of the evaluation. There is no fee to participate in this activity.

This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the US Food and Drug Administration. The CMSC and Intellisphere do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the CMSC or Intellisphere.

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health care professionals without first evaluating their patients’ conditions, considering possible contraindications or risks, reviewing any applicable manufacturer’s product information, and comparing any therapeutic approach with the recommendations of other authorities.

Sexual health is an integral part of overall well-being, encompassing emotional, psychological, and physical aspects that profoundly influence quality of life. Despite the prevalence of sexual dysfunction (SD) among people with multiple sclerosis (MS), it is too frequently underreported and undertreated. Sexual and gender minority (SGM) people with MS, in particular, may face stigma, discrimination, and clinician hesitancy that can bar access to necessary sexual health care. Recognizing SGM identity can help clinicians deliver more inclusive general and sexual health care, including but not limited to family planning and gender-affirming care. The 8 Ps model can aid in taking a nonjudgmental sexual history that allows for recognition of sexual dysfunction regardless of identity.

The authors have declared no relevant conflicts of interest.

The work of Tamara B. Kaplan, MD, in this area is generously supported by the Beker Foundation.

Addressing sexual health is fundamental to holistic care. The World Health Organization defines sexual health as a “state of physical, emotional, mental, and social well-being in relation to sexuality and not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

 As a vital part of emotional, psychological, and physical well-being, positive sexual health is associated with lower levels of depression and anxiety, higher quality of life, and greater life satisfaction in the general population.

Sexual dysfunction (SD) is defined as persistent or recurrent problems with sexual response, desire, orgasm, or pain that cause significant distress or interpersonal difficulty. The major categories of sexual dysfunction include disorders of sexual desire/interest, arousal, orgasm, and sexual pain.

 Multiple sclerosis (MS) can lead to SD, with reduced libido and difficulties with sexual arousal, function, and satisfaction, all negatively impacting sexual health. Although the majority of people with MS experience sexual dysfunction,

 there is notably little literature surrounding the intersection of neurological conditions, sexual wellness, and sexual and gender minority (SGM) identity. In this review, we summarize existing research on these topics, identify unmet needs for SGM people with MS, and suggest future research and clinical practice.

SD is a prevalent concern in people with MS; meta-analyses estimate that approximately 64% experience it.

Despite its high prevalence, SD is too often underreported, inadequately assessed, and undertreated in people with MS.

Neglecting sexual dysfunction ignores a substantial concern for this population, as recent studies have revealed that SD contributes more to mental health and quality of life than neurological disability in people with MS.

Although SD’s exact etiology in MS remains unclear, Foley et al proposed that it may manifest from primary, secondary, and tertiary causes.

Primary SD refers to problems that result from direct damage to the nervous system as a result of cortex and spinal cord demyelination; this may include symptoms such as genital numbness, decreased lubrication, and erectile dysfunction. Secondary causes are neurological symptoms and physical disabilities that affect sexual function, such as fatigue, spasticity, pain, and bladder and bowel dysfunction. Finally, tertiary causes result from psychosocial stressors associated with having MS. The majority of people with MS report that primary, secondary, and tertiary factors all contribute to their SD.

Treating SD in people with MS involves multidisciplinary interventions that aim to address both physical and psychological components. Pharmacologic treatments such as phosphodiesterase inhibitors for erectile dysfunction and topical estrogen for vaginal dryness in postmenopausal women can help manage physical symptoms.

 Psychotherapy has been shown to be effective in addressing emotional and relational challenges associated with SD, helping people with MS and their partners communicate effectively and rebuild intimacy.

 Additionally, physical therapy, including pelvic floor exercises,

 can improve muscle strength and control, thereby improving sexual function. Aquatic exercise

 has also been proven to improve self-reported sexual desire, arousal, lubrication, orgasm, satisfaction, and pain, while yoga

was associated with improved sexual satisfaction; both can be offered if people with MS seek nonpharmacologic or nontherapy strategies to address SD. This holistic approach to SD addresses the sexual health of people with MS by treating its primary, secondary, and tertiary causes.

Discussing sexual health necessitates an overview of SGM people, which is a group that is underrepresented when discussing approaches to SD in people with MS.

The SGM population includes individuals whose sexual identity, gender identity, or reproductive development differs from conventional societal, cultural, or physiological norms.

 SGM individuals represent approximately 7% of the global population,

 which is likely an underestimate due to past and present criminalization of and discrimination against this population in many parts of the world. Likewise, health care barriers in SGM populations are well-documented and include disparities in access to care, discrimination, and inadequate cultural competence among health care professionals, with transgender individuals facing the greatest inequities.

These SGM health care disparities can create a climate of reluctance to disclose sexual histories and problems in health care settings. A systematic review of many SGM individuals revealed that fear of unequal care, potential negative personal reactions from health care professionals, breaches in patient-clinician confidentiality, and documentation of SGM identity in medical records were all reasons for not disclosing their SGM identity in a health care setting.

Recent research indicates that those in the sexual minority may be more susceptible to SD compared with their heterosexual counterparts.

 This disparity is attributed to multiple factors, including higher rates of mental health issues within SGM populations

 and difficulties arising from societal perceptions of their relationships,

 both of which can negatively impact sexual satisfaction and functioning. Additionally, limited access to LGBTQ+ inclusive clinicians further restricts access to essential sexual health services.

Intersectionality of MS, Sexual Health, and SGM Identity

In the context of MS care, comfort with SGM identity disclosure and perceived discrimination remain concerns. A survey of Italian people with MS demonstrated that sexual minority individuals were more likely to switch MS centers compared with their heterosexual counterparts, with 85.7% reporting at least 1 experience of homophobic behavior from clinical staff.

 More recently, a survey of 285 people with MS who self-identified as SGM documented less comfort discussing sexual health with their clinician and less satisfaction with their clinician overall compared with heterosexuals.

 Similarly, Anderson et al found that 30% of SGM individuals with MS felt uncomfortable discussing their SGM identities with their clinician. Additionally, this group reported lower mean satisfaction scores in the domain of sexual health relative to other health domains.

Clinicians’ understanding of the SGM identities of people with MS is essential for bettering sexual and reproductive health. For example, all people with MS with gestational capacity must be made aware of disease-modifying therapy indications and timing surrounding pregnancy to ensure safe and informed family planning decisions. Considering that SGM individuals are often less likely to receive reproductive counseling,

 clinicians should proactively and nonjudgmentally inquire about reproductive goals to ensure safe pregnancy outcomes. However, a recent survey of American Academy of Neurology members’ preparedness to treat SGM individuals reported that one-third of those polled would not tailor neurologic care based on SGM identity, and 43% believed that sexual or gender identity has no bearing on the management of neurologic illness.

 Further, a scoping review of all SGM research in the field of neurology revealed that a mere 1.7% of SGM papers focus on MS.

 The paucity of literature concerning SGM people with MS could be contributing to neurologists’ decreased attention to the unique health care needs of this population, further exacerbating health care disparities for the SGM population.

Effective interventions are essential to overcoming barriers in SGM health. Two common reasons clinicians hesitate to take a sexual history are concern about making patients feel uncomfortable or feeling uncomfortable themselves. In an emergency department study, nearly 80% of clinicians believed patients would refuse to disclose their sexual and gender identity. However, only 10% of patients studied (including heterosexual individuals) stated they would withhold this information.

 Thus, if a clinician feels that inquiring about SGM identity is appropriate, they should feel confident in doing so, especially if done in a respectful and affirming manner.

The process of taking a sexual history is often thought of as a means of assessing risk for sexually transmitted infections and/or pregnancy. However, the conversation presents a meaningful opportunity to discuss multiple aspects of care for people with MS. In addition to considerations such as contraception or pregnancy planning for individuals with reproductive capacity, MS itself can lead to sexual problems, and many of the medications used to manage MS symptoms may further contribute to these issues (eg, baclofen and selective serotonin reuptake inhibitors are associated with SD), impacting quality of life.

 Proactively addressing the potential sexual adverse effects of medications can prevent frustration and help individuals make informed decisions about treatment options. For example, sexual issues are often treatable with changes in drug dosing time, amount, or duration, or additional therapies to increase function. Even if someone is not experiencing difficulties, having transparent, open-ended conversations can help put them at ease and will help them raise questions with their health care providers if the need arises.

Fenway Health, a Boston, Massachusetts–based clinic focusing on SMG health care, created the 8 Ps model for taking a comprehensive sexual history based on best-practice guidelines from the Centers for Disease Control, but modified to be more inclusive (

 For SGM people with MS, we pay particular attention to 

. As discussed previously, family planning should be discussed with all people with reproductive capacity. It is also important to clarify 

 and vocabulary so that counseling can be informative and affirming. People with chronic diseases

 are less likely than their healthy, cisgender, heterosexual peers to receive contraceptive counseling, highlighting the need for health care professionals to initiate these conversations to ensure inclusive, person-centered care and address potential disparities in reproductive health.

A survey of people with MS at a large, academic hospital found that more than one-third of women with MS had experienced abuse in their lives, consistent with the general population, and 15% had experienced abuse in the past year. Higher levels of neurologic disability were associated with increased experience of abuse.

Poor mental health, cognitive challenges, and difficulty managing disease all contribute to increased vulnerability.

SGM individuals are also at higher risk for experiencing abuse.

 Bisexual women are 1.8 times more likely to report experiences of intimate partner violence (IPV)—physical, sexual, emotional, or psychological harm caused by a current or former partner—and 2.6 times more likely to report sexual violence than heterosexual women. The lifetime prevalence of IPV among transgender people has been reported to range from 31% to 50%.

Given these statistics, it is crucial for clinicians to routinely ask about abuse in SGM people with MS and to involve social work services to provide appropriate support and interventions if indicated.

Sexual health significantly contributes to overall well-being, as sexual wellness is associated with decreased depression and anxiety and greater life satisfaction.

 Despite affecting the majority of people with MS,

SD remains too frequently underreported and thus undertreated.

SGM people with MS face disproportionate sexual health disparities; they are less comfortable discussing their sexual health with their clinicians and also report decreased satisfaction when doing so compared with heterosexual people with MS. Unfortunately, many experience homophobic behavior, prompting them to switch MS centers as a result.

 Many neurologists may still overlook the significance of SGM identity when managing MS.

Taken together, these barriers bar open patient-clinician communication, ultimately leaving SGM people with MS without the necessary support and interventions to treat SD effectively.

Neurologists can turn to adolescent oncology care for an example of where SGM health is prioritized. The National Comprehensive Cancer Network has published guidelines that emphasize the importance of creating an inclusive, safe, and comfortable space for SGM patients, writing that “integral to the comprehensive care of individuals with cancer…is an assessment for gender expression, gender identity, pronouns, and sexual identity.” These guidelines recommend involving SGM support persons identified by SGM patients, initiating referrals for psychosocial support, and considering referrals to specialized gender clinics for transgender youth.

Integrating SGM-affirming approaches into neurological care can enhance patient-clinician communication and trust, ultimately improving sexual health and overall well-being for this population. Implementing inclusive sexual history-taking methods, such as the 8 Ps, can open the door to discussing SD and family planning regardless of sexual and gender identity.

 Given the heightened vulnerability of both SGM individuals and people with MS to IPV, routine screening for this is critical and is part of the 8 Ps.

Beyond the neurologic visit, interdisciplinary care can help address sexual health concerns, facilitate inclusive discussions, and ensure comprehensive care for SGM people with MS. Given the increasing demands on physicians and limited visit times, referrals to psychologists, social workers, and physical therapists can enhance sexual health care for SGM people with MS. These interventions are summarized in 

Beyond making the clinical space more inclusive, adequately treating SD and improving sexual health in SGM people with MS requires more research, as our review of the literature identified several gaps in evidence surrounding this population. We did not identify any SD treatment trials that made note of sexual orientation, let alone any with a focus on SGM people with MS. Future SD treatment trials in people with MS should aim to include SGM individuals, and further qualitative studies surrounding their barriers to sexual health care and specific sexual health needs are essential. Research surrounding gender-affirming hormone therapy, especially as it relates to sexual health, in people with MS is also lacking and would greatly enhance care for this population.

Sexual and gender minority individuals with multiple sclerosis face additional challenges, including stigma, discrimination, and health care disparities, which can limit access to sexual health services, including family planning and gender-affirming care.

Unspoken Challenges: Sexual Health in Sexual and Gender Minority People With Multiple Sclerosis

The prevalence of osteoporosis is higher in people with multiple sclerosis (MS) compared with the general population. Poor bone health, including higher rates of osteopenia and osteoporosis than in the general population, has been established in people with MS. This qualitative study examines how much a group of health care professionals (HCPs) knows about osteoporosis as an MS comorbidity, as well as current practices, barriers to effective bone health management in people with MS, and recommendations for improvement.

Thirty-two Australian HCPs participated in qualitative interviews, including 4 neurologists, 8 endocrinologists, 9 MS nurses, 6 general practitioners, and 5 physiotherapists. Participants were recruited via email, phone calls, and network contacts. Due to a technical error with the recording of 1 interview, 31 interviews were transcribed using Otter.ai. They were reviewed for accuracy and analyzed through NVivo using framework analysis.

Most clinicians lacked specific knowledge regarding bone health in people with MS. While the heightened osteoporosis risk in people with MS was presumed, participants perceived current practices as insufficient or were uncertain about their adequacy. Lack of awareness and education about bone health in people with MS emerged as primary barriers, as did insufficient interdisciplinary communication, role delegation, funding, and resources, which were deemed essential for better management.

Clinicians advocated for specific guidelines, enhanced education for HCPs, increased resources for patients and clinicians, and improved access to bone health screening for people with MS. These findings underscore the need for comprehensive strategies, emphasizing collaboration, education, and resource allocation, to address the complexities of bone health in individuals with MS.

We thank the participants who contributed their time and insights to the study.

All authors report no relevant conflicts of interest.

Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease characterized by demyelination and axonal degeneration in the central nervous system, leading to many symptoms and resulting disabilities. Among the many consequences associated with MS, such as mobility impairment, cognitive dysfunction, and fatigue, there is a growing recognition of its impact on musculoskeletal health, particularly regarding osteoporosis, falls, and fracture risk,

 which pose significant challenges to an individual’s quality of life.

Symptoms such as imbalance, muscle weakness, uncoordinated movements, numbness, impaired vision, and vertigo predispose individuals to falls and subsequent fractures.

 Epidemiological studies have shown that people with MS have a higher prevalence of osteoporosis

 consistent with low bone mineral density.

 The prevalence of osteoporosis was recently reported to be 30% in people with MS compared with 9% in age- and sex-matched healthy controls under 65 years of age (median 28 years; range, 35-57 years) in an Austrian study.

 More broadly, a meta-analysis of 29 studies of people with MS, with a mean participant age of 41.5 years, reported the prevalence of osteoporosis at 17% and the prevalence of osteopenia at 43%. The prevalence of osteoporosis in adults over 50 years from the general population in high-income countries (ie, Australia, Europe, and the United States), ranged from 3% to 8% in men and 16% to 33% in women.

 This elevated risk stems from a combination of factors intrinsic to the disease process and secondary to its clinical manifestations. One example of this combination is that people with MS are often prescribed medications that may reduce bone density, including glucocorticoids, immunomodulators, antidepressants, anticonvulsants, anxiolytics, opioids, and antipsychotics.

Despite the substantial impact of osteoporosis on people with MS, there is a gap in current practice among health care professionals (HCPs). A qualitative study of 27 women with MS that examined knowledge of osteoporosis and experience with HCPs reported that several women answered no when asked, “Has anyone involved in your care spoken with you about osteoporosis?”

 Many women indicated that their physicians had suggested supplementation with calcium without an explanation for the recommendation.

 A Turkish study that assessed 325 people with MS reported that participants with MS had minimal knowledge of osteoporosis; however, participants with any fall risk had higher osteoporosis knowledge than those with no fall risk, suggesting clinicians may reactively provide osteoporosis education, rather than providing this information as a preventive measure.

 In the general population, studies of HCPs conducted in Canada, India, and Iran demonstrated insufficient knowledge regarding osteoporosis diagnosis and management, osteoporosis medications, and preservation strategies, indicating that for HCPs, poor understanding of bone health in people with MS is a global problem.

 Given that osteopenia and osteoporosis can be modified by lifestyle and pharmacological interventions, it is imperative that bone health be addressed by HCPs managing MS for their patients.

To address the gaps in the literature, we aimed to assess the HCPs’ knowledge about bone health specific to patients with MS and their current bone health practices, including in educating, evaluating risk, referring, and managing bone health. Specifically, we sought to (1) evaluate the current practices among HCPs for whom bone health in people with MS should be a consideration, including MS specialists, general practitioners (GPs), endocrinologists, and physiotherapists or exercise physiologists; and (2) identify the facilitators and barriers to improving bone health and the detection and management of osteoporosis in people with MS.

This qualitative study investigated perspectives of HCPs involved in the health care of people with MS. This research was guided by framework analysis, which includes the subjective experience of the research participants and concepts and issues identified in the literature.

 The research team included MS, musculoskeletal, and health care researchers, clinicians and trainees, as well as people with MS, all of whom provided expert input into the development of the interviews, validation of the analysis, and drafting/editing of the results. All interviews were undertaken by a trainee clinician (L.A.J) under the supervision of senior researchers with qualitative research expertise (L.G., A.Z.).

HCPs were recruited through network contacts, via email and phone calls (convenience sample), between December 2022 and March 2023. Inclusion criteria were access to an internet connection and Zoom, and being a registered and practicing HCP, including neurologists, endocrinologists, MS nurses, general practitioners (GPs), and physiotherapists/exercise physiologists. With the exception of neurologists and nurses, participants were not required to be managing the health care of people with MS at the time of the interview, but were in health care roles where they could encounter patients with MS. Study ethics approval was granted by the Monash Health Human Research Ethics Committee (project number: RES-22-0000579A). Participants provided recorded, verbal informed consent.

Interviews were conducted and recorded via Zoom. Interviews followed a semistructured interview guide consisting of questions about general demographic characteristics, knowledge of bone health and MS, current practices (including use of the Fracture Risk Assessment tool [FRAX], an international reference standard tool to assess osteoporotic fracture risk

), barriers and facilitators in managing bone health in people with MS, and recommendations to improve practices (see Grech Supplemental at the bottom of this article). Responses were unstructured, and participants were prompted with further questions as required. Deidentified interviews were transcribed using Otter.ai and reviewed for accuracy by the interviewing researcher (L.A.J.).

Transcripts were stored and coded in NVivo 12 Plus (QSR International). Transcripts were coded by 1 author (L.A.J.) and checked for coding accuracy and quality by a second author (L.G.). The data were independently analyzed by these 2 authors using a framework developed a priori by the researchers from research literature concepts, qualitative interviews with people with MS, and the research goals. The framework utilizes subthemes specific to the health professional where relevant and was expanded to incorporate emergent themes and subthemes consistent with framework analysis.

 Quotes were grouped according to themes and are identified by HCP. The approximate scale of the proportion of participants that identified with a theme or sentiment is as follows: 

 Given the qualitative nature of this work, these percentages should be used as a guide to the level of response consistency and not for broad generalization.

Interviews were conducted with 32 Australian HCPs, including 4 neurologists, 8 endocrinologists, 9 MS specialist nurses, 6 general practitioners, and 5 physiotherapists. The analysis included 31 interviews due to a technical error with the interview recording with 1 of the physiotherapists. HCPs worked in settings ranging from public hospitals to private practice, predominantly in the states of Victoria and New South Wales. A similar number of men and women participated in the study, and most were between the ages of 30 and 49 years (

). The average interview duration was 26.5 minutes (range, 12-48 minutes), with the shortest interview times among the neurologists (median [

] = 17.8 minutes) and the longest among the nurses (

Knowledge About Bone Health Specific to MS

None of the HCPs interviewed knew the prevalence of osteoporosis in people with MS. When asked if osteoporosis was more common in people with MS, a few MS nurses and half of the GPs were certain there was an increased osteoporosis risk in people with MS (

). Most HCPs acknowledged knowing little about bone health related to MS specifically.

HCPs identified various risk factors associated with lower bone density in individuals with MS. These included mobility issues, higher disability, reduced activity (particularly weight-bearing exercise), increased falls leading to fracture risk, inadequate vitamin D, and low calcium intake. Half of the MS nurses recognized the impact of MS diets on vitamin deficiency as a risk factor. The high use of glucocorticoids for MS relapses was identified as a risk factor for osteoporosis. HCPs were unaware of specific guidelines for managing bone health in people with MS.

Current Management of Bone Health in People With MS

Education about bone health, osteopenia, and osteoporosis. 

None of the HCPs reported providing specific education on bone health, osteopenia, or osteoporosis in the context of people with MS. Half of the neurologists responded to questions raised by their patients with MS and referred them to their GP for further information. GPs noted that bone health was not commonly addressed in the context of MS care. 

Lifestyle recommendations for bone health. 

MS nurses, neurologists, and physiotherapists commonly provided healthy lifestyle recommendations to people with MS. While most MS clinicians suggested practices beneficial for bone health, such as addressing low vitamin D intake, promoting a healthy diet, and increasing exercise, these recommendations were often framed within the context of improving overall MS outcomes rather than specifically emphasizing bone health. Similarly, physiotherapists focused on exercises that contributed to better bone health and the prevention of falls in people with MS, including strength and balance training and aerobic exercises.

MS clinic assessment of risk, mobility, falls, and fractures. 

Most MS nurses reported that physical assessments were routinely performed at clinic appointments. This was generally in the form of a neurological-focused assessment, most often using the Expanded Disability Status Scale, administered by the clinic neurologists. Nurses were divided when asked if they assessed for injuries, falls, and fractures. Some said they did this routinely, while others probed further only if the patient brought up a decline in mobility or mentioned a fall. None of the MS nurses or neurologists used the FRAX tool to assess absolute fracture risk in people with MS.

All HCPs stated that bone density screening was inadequate in people with MS. Most HCPs considered bone health screening important, and some thought that screening should be initiated earlier for individuals with MS than for the general population. More broadly, suggestions of how often screening should occur ranged from yearly to every 2 years, with a follow-up duration dependent on baseline bone density.

Management of bone health and osteoporosis. 

When asked if management of bone health was adequate for people with MS, responses varied depending on the discipline. Some nurses suggested bone health was not adequately managed and that health care services and management varied by service. Some physiotherapists responded that they did not specifically focus on bone health in clients with MS. Half of the endocrinologists stated that their patients with MS had good osteoporosis management.

Most HCPs reported having specific knowledge of and providing monitoring for medications and adverse effects related to their specialty only. For example, MS neurologists and nurses monitored medications related to MS, and endocrinologists monitored osteoporosis medications. Except for endocrinologists, most HCPs did not know which medications negatively impacted bone health other than glucocorticoids. Many MS nurses and neurologists did not inform patients about the potential negative effects on bone health after prescribing or ceasing medication, and none of the MS clinicians had referred MS patients for a bone density scan (ie, dual energy X-ray absorptiometry, DXA) after prescribing or discontinuing medication.

Barriers and Facilitators to Managing Bone Health

Most MS nurses and neurologists considered bone health screening and management to be the responsibility of GPs. Many MS clinicians reported only seeing people with MS every 6 to 12 months when they were stable and indicated that bone health was not a priority, given limited consultation time. Some MS clinicians reported that the difficulties with mobility and multiple other disease-related factors in patients with more complex MS created a barrier in identifying low bone density.

Most endocrinologists considered the bone health management role to be multidisciplinary, but indicated that GPs had a pivotal role. There was broad agreement by HCPs that they would liaise with the patient’s GP about issues related to bone health, although a few endocrinologists acknowledged that they communicated with the neurology team rather than the GP. GPs noted that they often focus on other clinical aspects related to MS or the person’s health care more broadly.

Most HCPs acknowledged the need for multidisciplinary health care to manage bone health in people with MS, including physiotherapy, occupational therapy, dietetics, endocrinology, and podiatry. Some HCPs communicated with other team members, and some deferred to the GP as the communication coordinator. In the management of falls and fractures, many MS nurses and some neurologists highlighted the importance of involving allied health professionals to facilitate physical conditioning and prescribe equipment to prevent falls, such as braces, orthotics, and gait equipment.

Lack of awareness and information about poor bone health in people with MS were identified as barriers by half of the HCPs interviewed. Some suggested they would benefit from educational resources, such as fact sheets or other written information, online learning modules, or seminars.

HCPs were unaware of bone health resources specific to people with MS. Some HCPs, predominantly endocrinologists, suggested that the resources would be similar to those for the general population. HCPs suggested that patient education should be provided by MS community service organizations through webinars, peer support groups, and other communication modalities.

Most HCPs acknowledged a need for improved practice regarding bone health in people with MS, including standardized pathways to screen and identify patients with MS at risk of medication-related poor bone health. Some nurses and half of the endocrinologists suggested that guidelines for the prevention, detection, and management of osteoporosis in people with MS would be helpful for HCPs.

When asked if bone health in people with MS should be treated in the same way or in a different way than the general population, most HCPs pointed to the need for a different approach. Reasons for differences in management included the need for a greater focus on fall risk education and the need for exercise to maintain bone health and improve balance to minimize falls. To support these needs, a referral to an allied health professional was suggested. In contrast, a few HCPs responded that they would treat people with MS no differently than other patients.

Most endocrinologists stated that people with MS often pay for bone density scans because they do not meet the criteria for a government (ie, Medicare) subsidized scan; if required, they also believed that some of their patients would also need to pay for medications to maintain or improve their bone density. A few endocrinologists identified the absence of a government subsidy to screen bone density in people with MS as a screening barrier, especially for people of lower socioeconomic status. A few endocrinologists and half of the GPs noted that a government subsidy would assist with better detection of low bone density to enable appropriate management.

This research assessed current practices as well as barriers to and facilitators of bone health management across HCPs working with people with MS, including GPs, MS nurses, neurologists, endocrinologists, and physiotherapists. We found (1) HCPs had little knowledge about bone health specific to people with MS; (2) an absence of health care and lifestyle self-management information about risks for poor bone health and prevention; (3) insufficient bone health risk assessment, screening, and management in people with MS; (4) a need for improved multidisciplinary coordination and support; and (5) a need for management guidelines, training, and educational resources for HCPs. Our findings are consistent with previous research where people with MS reported that HCPs did not address osteoporosis in consultations, as well as with research assessing HCPs more broadly that demonstrated insufficient knowledge regarding osteoporosis diagnosis and management, osteoporosis medications, and bone-health preservation strategies.

The majority of HCPs acknowledged knowing little about bone health in people with MS, and none of the HCPs interviewed knew the prevalence of osteopenia and osteoporosis in people with MS. Most HCPs were able to identify several risk factors, including reduced mobility, higher disability, reduced physical activity, and inadequate vitamin D and calcium intake. The only treatment HCPs recognized as a potential risk factor for poorer bone health was the high use of glucocorticoids. Although further high-quality research is required to fully understand the impact of medication on bone health in people with MS,

 current research endorses an increased risk of fracture from a number of medications often prescribed for people with MS, including antidepressants, anxiolytics, anticonvulsants, opioids, and antipsychotics.

 None of these medications were mentioned as potential risk factors for people with MS by HCPs during the interviews. In Australia, around 35% of people with MS take antidepressants compared with 8% to 10% of the general population.

 Further, autologous hematopoietic stem cell transplantation (AHSCT), an increasingly common treatment for MS, has established risks for bone health and fragility fractures.

 While guidelines for AHSCT for people with MS refer to concerns about late effects, there is no mention of bone health or associated monitoring requirements.

 This deficit in interdisciplinary knowledge potentially increases the underdiagnosis of osteopenia and osteoporosis.

In our study, HCPs acknowledged that bone health risk assessment, screening, and management were inadequate in people with MS. The reason is multifactorial, including the lack of awareness of the higher prevalence of osteopenia and osteoporosis in people with MS among HCPs, and financial barriers to bone density screening by DXA. The HCPs interviewed were unable to identify any guidelines for bone health management in people with MS. Consistently, we identified limited referral for bone screening for at-risk patients. While guidelines to support bone health management in people with MS are limited,

 an evidence-based guideline that is focused on clinical management of MS exacerbations recommends baseline and annual bone density screening for people who undergo repeated glucocorticoid treatment for MS exacerbations.

We found that a lack of government-funded bone density screening also limits referral. In Australia, to be eligible for a government-funded DXA scan, a person must be 70 years of age or older, or have 1 of the following: (1) one or more minimal trauma fractures in the past 10 years; (2) be over 50 years of age with early menopause, hypogonadism, prolonged glucocorticoid therapy, celiac disease or malabsorption disorders, rheumatoid arthritis, primary hyperparathyroidism, hyperthyroidism, chronic kidney or liver disease, or androgen deprivation therapy.

 Most people with MS do not fall into any of these categories, despite evidence of a younger age of osteopenia and osteoporosis onset.

 As such, they may be overlooked or not able to undergo a DXA scan due to the high out-of-pocket cost. Endocrinologists noted that this creates a health care barrier and a socioeconomic divide, placing people with MS with lower socioeconomic status at risk of poorer health outcomes,

 including comorbidity and mortality. Musculoskeletal conditions are recognized as being among the most prevalent and costly comorbidities in people with MS, resulting in high losses to productivity and resource costs.

 There is a clear need to proactively deliver health care services to prevent bone health degeneration.

We found that a lack of multidisciplinary coordination among HCPs contributes to the barriers to patient education, assessment, and management of bone health in people with MS. Most HCPs who treat patients with MS considered bone health management to be the responsibility of the GP. Improved multidisciplinary health care for people with MS has been previously called for with the proposed development of MS care units.

 Examples from cancer and chronic kidney disease clearly provide evidence that multidisciplinary health care teams result in better health outcomes in people with multimorbidity.

 The National Comprehensive Cancer Network Task Force was formed to ensure that multidisciplinary health care teams have guidelines to provide optimal assessment and treatment of bone-related issues in patients with cancer.

 Multidisciplinary health care teams managing patients with cancer have resulted in significant reductions in skeletal complications, bone pain, and fracture risk, as well as improved quality of life.

There is insufficient bone health risk assessment, screening, and management; there is also an absence of health care and lifestyle self-management information about the risk and prevention of poor bone health for people with multiple sclerosis.

Odalys Arbelaez, MA

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